Javier García Fernández. MD. Ph.D. MBA. Chairman of Anaesthesia and Critical Care Service Puerta de Hierro University Hospital Associate Professor.

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1 Javier García Fernández. MD. Ph.D. MBA. Chairman of Anaesthesia and Critical Care Service Puerta de Hierro University Hospital Associate Professor. Medical School. UAM

2 CV and Conflict of interest Chairman of Anaesthesia, Critical Care and Pain Department. Puerta de Hierro Univ. Hospital. Madrid Ph.D. UCM. Madrid MBA. UCM. Madrid Expertise: Pediatric Anaesthesia and critical care, mechanical ventilation. SCIENTIFIC ACTIVITY Patents: 1 Oral presentations: 85 Lectures: 152 Book Editor: 3 ; Book Chapters: 33 Director of Ph.D.: 3 Grants and Prizes: 12 Director of training course s: 14 Journal associated editor : 4 Journals Referee: 4 Indexed publications (Medline): 55; F.I. 45,99 I have received research grants from: Maquet, GE, Dräger, Spacelab, Masimo, Covidine, Abbot and Baxter I have been invited to form part of the advisory board of several of those companies but I prefer to keep independent and open to what new technologies are offering to us I don t have any conflict of interest for this lecture but..i don t want you to go sleep so I am going to provoke you

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5 Before PNEUMOPERITONEUM 6 months all patient; 6 Kg Dx: hiatus hernia Qx: laparoscopic Nissen. After PNEUMOPERITONEUM

6 University of Michigan Medical Center, review of all operations performed between , using a general anesthetic which at least 1 arterial blood gas determination was made. 83,866 ABGs were obtained in 27,101 patients Excluding cardiac and thoracic procedures Four cohorts of arterial blood gases were identified with P/F > 300, P/F= , P/F = , P/F < 100. Positive end-expiratory pressure (PEEP), peak inspiratory pressures (PIPs), FIO2, oxygen saturation (SaO2), and tidal volume in ml/kg PBW were compared A&A ;

7 A&A ;

8 A&A ;

9 Conclusions Similar ventilation strategies in ml/kg PBW and PEEP were used among patients regardless of P/F ratio The results of this study suggest that anesthesiologists, in general, are treating hypoxemia with higher FIO2 and letting increase the PIP, but never use low Vt, high levels of PEEP and recruitment maneuvers as in intensive care units are starting to do for improving oxygenation A&A ;

10 To keep learning, sometimes, it is crucial to unlearn, what you have studied before Aristotle

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13 VOLUME , February, 5 NUMBER 6 NUMBER 6

14 Cumulative Survival Survival function - Amato et al Protective.6 P < N = 53 Control Time after Entry ( days )

15 ARDS net. N Engl J Med 2000;342: N = ml/kg 12 ml/kg

16 Evolution of Mortality in ARDS Phua et al. Am J Respir Crit Care Med 2009; Permissive Hypercapnia AECC 44% observational 36% in RCT

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19 Mechanical ventilation and healthy lungs Dreyfuss D y col. Am Rev Respir Dis 1993.

20 What is low or high Vt in thoracic surgery for you? Unit of measurement : (ml) Know the minimum and maximum valor used: Minimum: 2-3 ml/kg HFOV Maximum: 32 ml/kg Role of free radicals in vascular dysfunction induced by high tidal volume ventilation. Martínez-Caro L et al. Intensive Care Med Media: 15 ml/kg ASA guidelines 2004 recommended the use Vt 15 ml/kg for avoiding hypoxemia in one-lung ventilation in thoracic surgery

21 Mechanical ventilation and healthy lungs

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24 Mechanical ventilation and healthy lungs EDITORIAL : Mechanical ventilation is a massive destructive weapon or a powerful tool of freedom McCunn y col. Crit Care Med 2003.

25 What is optimal ventilation or protective ventilation? In what parameters is based on? Optimal ventilation : MV using the less pressure possible to obtain the minimum minute volume to cover the oxygen-demand and CO2 removal required for the body for this patient in this specific moment Protective ventilation: Mechanical ventilation avoiding VILI

26 Mechanical Ventilation objectives Oxygenation: Do you intubate a patient with Sat O2 80 %? Acute/chronic Progressive / stable Ventilation: EtCO2 of 30 mmhg is the ideal ventilatory objective? COPD patients the ph is giving you the answer

27 Why would an adult anesthetist who is never going to anesthetize children be interested in mechanical ventilation for pediatric anesthesia?

28 Because the healthy lungs of neonates and of infants under 5 kg in weight, are a good physiological model for altered pulmonary states in adults.

29 Neonatal lungs are perfect model for ARDS states in adults: Neonatal lungs have: Low FRC / high closure volume very prone to have atelectasis during any disconnection Low pulmonary compliance (dynamic and static) Low inspiratory and expiratory times High rate of oxygen consumption (double than adult). High airway resistances

30 Compliance (ml/cmh2o) Compliance dyn (cmh 2 O/l/s) vs weight (kg) 60,00 50,00 40,00 30,00 20,00 10,00 0, weight (kg) Study done in pediatric patients from 4 kg-60 kg. C dyn = 1 ml/cmh2o / kilo of weight until 50 kg García-Fernández J, Tusman G, Suárez-Sipman F, Llorens J, Soro M, Belda J. Anestesia & Analgesia 2007: 105:

31 airway resistance (cmh2o/l/s) Airway resistance (cmh 2 O/l/s) vs age (years) Age (years) Inspiratory airway resistance is 7-10 times higher in newborns than in adults (>75 cmh2o/l/s vs cmh2o/l/s). In premature babies, inspiratory airway resistance can exceed 150 cmh2o/l/s J. Garcia-Fernandez et al. Current Anaesthesia & Critical Care 21 (2010);

32 Lung Volume Relation between FRC and closing volume. Differences between adults and neonates Glottic Closure Reflex: Glottic closure stops expiration before lung volume decreases below the pulmonary closing volume. (This can be called the physiological AUTOPEEP we are all born with and it is about 2-3 cm H 2 O) Harris T. Physiological Principles At: JP Goldsmith, EH Karotkin ed. Assisted Ventilation of the neonate. Philadelphia WB Saunders Co. P

33 Diaphragm function to keep FRC above closing volume spontaneus ventilation IPPV with diaphragm relaxation

34 Lung compliance: (elastic recoil) adult versus neonate

35 Non-anaesthesiated healthy rabbit J.B. Borges. Mechanical Ventilation Course. Madrid 2010.

36 Anaesthesiated rabbit after inducction J.B. Borges. Mechanical Ventilation Course. Madrid 2010.

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38 Why and when do atelectasis form? FRC / EELV Closing volume Open lung Atelectasis

39 Gravity Courtesy of Dr. J.B. Borges. Mechanical ventilation course. Madrid. 2009

40 Apneic oxigenation time: Directly proportional to FRC

41 Protective ventilation 1. PEEP must be program individually and after obtained an open lung (after Recruitment maneuvers). 2. Protocol of no disconnection no suction 3. Vt of 6 ml/kg doesn't guaranty to avoid VILI. Watch out DRIVING PRESSURE!!! and the role is the less the better 4. No fix and constant I:E relation and better high respiratory rate than high driving pressure (Physiological programming)

42 Protective ventilation 5. Individualize the oxygenation and hypercapnia level in each patient each day (Permissive or adaptive hypercapnia for ph > 7,2) 6. FiO 2 < 0.7 TIMING IS CRUTIAL (THERAPEUTIC WINDOW) 7. Fluid balance (MOST OF THIS ACTIONS WORK WELL IF YOU APPLY 8. Prono THEM sometime WITHIN helps improving THE V/Q FIRST 2-3 DAYS OF THE ONSET OF ARDS) 9. Induced hypothermia: (34-35º C) and paralysis in extreme difficult ventilate situations 10. Mechanical assistant devices: CO 2 removal systems or respiratory ECMO

43 Lessons from pulmonary physiology... This must be apply to any ventilator

44 English version: This advanced mechanical ventilation course is designed for experienced hospital staff with at least four years experience in ventilation techniques and is especially appropriate for professionals such as Chiefs of Department, Unit Coordinators or Resident Tutors, who are responsible for training other professionals. There are only 15 places per course

45 Thank you!!! Questions?

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